Left atrial pressure is associated with iatrogenic atrial septal defect after mitral valve clip

Hiroki Ikenaga; Atsushi Hayashi; Takafumi Nagaura; Satoshi Yamaguchi; Jun Yoshida; Florian Rader; Robert J Siegel; Saibal Kar; Takahiro Shiota

doi:10.1136/heartjnl-2018-313839

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Valvular heart disease

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Left atrial pressure is associated with iatrogenic atrial septal defect after mitral valve clip

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Iatrogenic atrial septal defect: size matters
Omar Abdul-Jawad Altisent, Victoria Vilalta, Eduard Fernandez-Nofrerias, Evelyn Santiago, Roger Villuendas, Gladys Junca, Francisco Gual, Xavier Carrillo, Oriol Rodrigez-Leor, Josefina Mauri, Josep Lupon and Antoni Bayés-Genís
Published on: 17 January 2019

Published on: 17 January 2019
Iatrogenic atrial septal defect: size matters
- Omar Abdul-Jawad Altisent, Interventional cardiologist MD, PhD, Germans Trias i Pujol University Hospital (Barcelona, Spain)
- Other Contributors:
  Victoria Vilalta, Interventional cardiologist
  
  Eduard Fernandez-Nofrerias, Interventional Cardiologist
  
  Evelyn Santiago, Cardiologist
  
  Roger Villuendas, Cardiologist
  
  Gladys Junca, Cardiologist
  
  Francisco Gual, Cardiologist
  
  Xavier Carrillo, Interventional cardiologist
  
  Oriol Rodrigez-Leor, Interventional Cardiologist
  
  Josefina Mauri, Interventional cardiologist
  
  Josep Lupon, Cardiologist
  
  Antoni Bayés-Genís, Cardiologist
To the Editor,
We read with interest the paper by Ikenaga et al. (1), who must be commended for their detailed report on the determinants of persistent iatrogenic atrial septal defect (iASD) following percutaneous mitral valve clip (MV clip) placement. The authors found that elevated left atrial (LA) pressure after the MV clip procedure was the main determinant of persistent iASD during follow-up. Remarkably, in spite of their poorer clinical condition, patients with and without persistent iASD had similar outcomes during follow-up. This suggested that interatrial shunt has a benefit in some MV clip patients. Previous studies that evaluated the usefulness of an interatrial shunt device for treating heart failure patients without valve disease also showed a significant benefit of the shunt in patients with high LA pressure (2, 3).
However, these findings disagree with other findings of the persistence of iASD after MV clip placement with negative outcomes, mainly due to right ventricle (RV) claudication (4). Indeed, previous studies of the interatrial shunt device suggest that the size of the shunt plays a key role in outcomes. Indeed, the ideal shunt size should allow the reduction of LA pressure without hampering right heart function. The maximum interatrial shunt devices are 5 mm2 (3); too large iASDs may increase the Qp/Qs enough to cause RV failure, while too small iASDs may be have negligible hemodynamical and clinical results. No MV clip studies reported...
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To the Editor,
We read with interest the paper by Ikenaga et al. (1), who must be commended for their detailed report on the determinants of persistent iatrogenic atrial septal defect (iASD) following percutaneous mitral valve clip (MV clip) placement. The authors found that elevated left atrial (LA) pressure after the MV clip procedure was the main determinant of persistent iASD during follow-up. Remarkably, in spite of their poorer clinical condition, patients with and without persistent iASD had similar outcomes during follow-up. This suggested that interatrial shunt has a benefit in some MV clip patients. Previous studies that evaluated the usefulness of an interatrial shunt device for treating heart failure patients without valve disease also showed a significant benefit of the shunt in patients with high LA pressure (2, 3).
However, these findings disagree with other findings of the persistence of iASD after MV clip placement with negative outcomes, mainly due to right ventricle (RV) claudication (4). Indeed, previous studies of the interatrial shunt device suggest that the size of the shunt plays a key role in outcomes. Indeed, the ideal shunt size should allow the reduction of LA pressure without hampering right heart function. The maximum interatrial shunt devices are 5 mm2 (3); too large iASDs may increase the Qp/Qs enough to cause RV failure, while too small iASDs may be have negligible hemodynamical and clinical results. No MV clip studies reported iASD size, which can easily be estimated by Doppler. Thus, sizing the residual iASD may be appropriate following a MV clip procedure. Furthermore, MV disease is often associated with significant pulmonary hypertension and with right heart damage (i.e. tricuspid regurgitation). Thus, even a small interatrial shunt may be deleterious, causing progressive right heart overload and dysfunction. This is the likely scenario in a significant number of MV clip patients (2,3).
Ongoing phase 3 randomized clinical trials in heart failure should provide further insights into the effects of an interatrial shunt. REDUCE LAP-HF II (NCT03088033) is a randomized controlled trial comparing the clinical efficacy of an interatrial shunt device versus optimal medical treatment in symptomatic patients with left ventricular ejection fraction (LVEF) >40%. REDUCE LAP HF-III (NCT03191656) is recruiting patients with preserved or mildly reduced LVEF to determine the benefits (functional status, quality of life) of this therapy at a 12-month follow-up. RELIEVE-HF (NCT03499236) is a randomized controlled trial comparing the second generation (valveless) V-Wave device with optimal medical therapy in patients with preserved or reduced LVEF.

REFERENCES
1 Ikenaga H, Hayashi A, Nagaura T, Yamaguchi S, Yoshida J, Rader F, Siegel RJ, Kar S, Shiota T. Left atrial pressure is associated with iatrogenic atrial septal defect after mitral valve clip. Heart. 2018. pii: heartjnl-2018-313839. doi: 10.1136/heartjnl-2018-313839. [Epub ahead of print]
2 Rodés-Cabau J, Bernier M, Amat-Santos IJ, Ben Gal T, Nombela-Franco L, García Del Blanco B, Kerner A, Bergeron S, Del Trigo M, Pibarot P, Shkurovich S, Eigler N, Abraham WT. Interatrial shunting for heart failure: early and late results from the first-in-human experience with the v-wave system. JACC Cardiovasc Interv. 2018 Nov 26;11(22):2300–10.
3 Del Trigo M, Bergeron S, Bernier M, Amat-Santos IJ, Puri R, Campelo-Parada F, Altisent OA, Regueiro A, Eigler N, Rozenfeld E, Pibarot P, Abraham WT, Rodés-Cabau J. Unidirectional left-to-right interatrial shunting for treatment of patients with heart failure with reduced ejection fraction: a safety and proof-of-principle cohort study. Lancet. 2016 Mar 26;387(10025):1290–7.
4 Schueler R, Öztürk C, Wedekind JA, Werner N, Stöckigt F, Mellert F, Nickenig G, Hammerstingl C. Persistence of iatrogenic atrial septal defect after interventional mitral valve repair with the MitraClip system: a note of caution. JACC Cardiovasc Interv. 2015 Mar;8(3):450–9.
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Conflict of Interest:
None declared.
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